Conclusions

Comparative clinical research on nonpharmacologic treatments for TRD is in its infancy. Comparative outcomes for both ECT and rTMS are similar, with no synergistic effect from combining these therapies. Regarding efficacy, indirect evidence suggests that rTMS is effective in response and remission over sham treatment. The effectiveness of ECT was not addressed in the review. No benefit was seen for VNS over sham treatment. Evidence regarding adverse effects is limited.